Provider Demographics
NPI:1417061953
Name:TECUMSEH MEDICAL CLINIC PHARMACY LLC
Entity Type:Organization
Organization Name:TECUMSEH MEDICAL CLINIC PHARMACY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-598-6597
Mailing Address - Street 1:418 E WALNUT ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TECUMSEH
Mailing Address - State:OK
Mailing Address - Zip Code:74873-2200
Mailing Address - Country:US
Mailing Address - Phone:405-598-6597
Mailing Address - Fax:405-598-6103
Practice Address - Street 1:418 E WALNUT ST
Practice Address - Street 2:SUITE 100
Practice Address - City:TECUMSEH
Practice Address - State:OK
Practice Address - Zip Code:74873-2200
Practice Address - Country:US
Practice Address - Phone:405-598-6597
Practice Address - Fax:405-598-6103
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-19
Last Update Date:2017-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
333600000X, 3336L0003X
OK10-52673336C0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No333600000XSuppliersPharmacyGroup - Single Specialty
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2074942OtherPK
OK100244260AMedicaid
OK90003922259Medicaid